Health inspection·February 23, 2023

F 0686 R8's 2/17/23 wound physician note showed a Stage 3 pressure injury to the left heel ,and recommended to offload the wound and float heels in bed. Level of Harm - Minimal harm or potential for actual harm R8's 11/14/22 pressure risk assessment showed R8 was at risk for developing a pressure injury. Residents Affected - Few The facility's January 2023 incident/accident log showed on 1/1/23 a left heel wound was noted. The facility's 2/18/23 to 2/24/23 pressure injury tracking form showed R8 had a Stage 3 pressure injury with an onset date of 1/1/23 that was acquired at the facility. The facility's 5/2021 Pressure Ulcer/Injury Prevention Protocol showed the resident will be free of a preventable skin breakdown. Protect heels as needed. Heels may need to be floated off bed. Do not position resident on pressure ulcer side if possible. A pressure ulcer/injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. A Stage 3 pressure injury is fullthickness loss of skin, in which subcutaneous fat may be visible in the ulcer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to serve liquids at a safe temperature to prevent burns, and failed to supervise residents at risk for burns and with poor safety awareness for 3 of 9 residents (R9, R32, R33) reviewed for safety and supervision in the sample of 23. These failures resulted in R32 sustaining a partial thickness burn to his right foot. The findings include: 1. R32's face sheet showed a [AGE] year-old male with diagnosis of hemiplegia and hemiparesis following a subarachnoid hemorrhage affecting the right dominant side, major depressive disorder, history of malignant neoplasm of bladder and hypertension. R32's 8/24/22 incident report showed staff noted a wound to his right dorsal foot and the resident stated he spilled coffee on his foot yesterday. The right foot had a 6 centimeter (cm) X 3 cm blister and a 2.5 cm X 2.5 cm X less than 0.1 cm wound. The report showed the interventions initiated was blank. R32's 8/24/22 progress note showed resident has new wounds on right foot from coffee burn. There is no wound assessment or other data regarding the incident. A late entry note showed there was partial skin loss and blistering noted to the right foot. Again, there were no measurements or other data noted in the record. R32's 1/1/23 facility assessment showed moderately impaired cognition. This assessment showed R32 was totally dependent on two plus persons physical assistance for toilet use, transfer, and bathing. Bed mobility, dressing, and personal hygiene required extensive assistance of two plus persons to physically assist but once up in his electric wheelchair R32 was independent to move around the facility. R32's safety and skin care plans have no interventions to prevent additional burns. An intervention present showed-if I refuse assistance to get a cup of coffee, provide education on the possible consequences (resident is moderately cognitively impaired). There is no plan to add a cup holder to R32's wheelchair. There is no mention of the 8/24/22 burn incident in R32's care plans. R32's 2/14/23 incident report showed he was transporting a hot cup of coffee from the dining room to his room holding the cup between his thighs. The coffee spilled onto his feet. The right foot had burns from the inner ankle on to the bottom of the foot. The wound measured 14.5 cm X 9.5 cm with partial skin loss and partial blistering. The report showed R32 needed a cup holder on his electric scooter. R32's 2/14/23 progress note showed R32's daughter was updated about the resident spilling coffee onto his feet causing a burn onto his right foot. The note showed the resident returned to the dining room, obtained another cup of coffee and spilled that one as well. Per the note, R32's daughter told the facility he used to have a cup holder on an electric wheelchair and that helped him transport cups of coffee as he has a weak right side. R32's 2/17/23 Wound Physician note showed two wounds to the right foot. Wound #1 showed an etiology (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 of trauma/injury to the right proximal, medial foot measuring 7.8 cm X 3 cm X 0.1 cm. Wound #2 showed an etiology of a burn to the right dorsal foot measuring 13.5 cm X 4.9 cm X 0.1 cm. Level of Harm - Actual harm Residents Affected - Few R32's 2/22/23 incident report showed the resident spilled hot coffee on his left thigh. The area was reddened with a broken blister area that measured 25 cm X 2 cm. On 2/23/23 at 8:40 AM, R32 was in bed. There were 3 empty coffee cups on the bedside table next to him, and the blanket over him had a large coffee stain on it. R32's electric wheelchair was in the room. There was no cup holder attachment on the wheelchair. Access to hot liquids in R32's dining area is not restricted or monitored. On 2/23/23 at 9:43 AM, V4, Wound Nurse, removed the dressing to the wound on R32's right medial foot. There was a large open blister that extended down the side and then the bottom of the right foot. There was another bandage over R32's left knee area. On 2/22/23 at 1:03 PM, V9, Dietary Manager, said a safe temperature for liquids to be served to residents is 165 degrees Fahrenheit. V9 said, I know residents have had burns (from hot beverages). That's why we started putting ice in the hot drinks after (R9) was burned (1/29/23). On 2/23/23 at 9:48 AM, V5, Registered Nurse, said the dressing to R32's left knee area is another burn from his coffee. V5 described the area on R32's left knee as approximately 6 inches long with a blister. R32's new burn wound was not observed as the dressing was not due to be changed. V5 said the burn to his left leg happened 2/22/23. A list of resident burns from hot beverages was requested. The handwritten list received did not include R32's 2/14/23 burn. (This list was received prior to R32's 2/21/23 burn). The National Institute of Health website (nih.gov) showed a burn takes place when the skin comes into contact with a heat source. The most common sources that cause burns are fire/flame, scalds, hot objects, electrical, and chemical agents, respectively. The skin location, the degree of temperature, and duration are contributing factors to the severity of the burn. There is a synergistic effect between the temperature and duration of exposure. Skin exposure to 140 degrees Fahrenheit (F) (60 degrees Celsius) for 10 seconds can cause a full-thickness burn. Some burns, especially partial-thickness, may progress over 2 to 4 days, peaking at day 3. Partial Thickness superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days. Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring. Deep partial-thickness (second-degree) involves the deeper dermis. It appears yellow or white, is dry, and does not blanch with pressure. There is minimal pain due to a decreased sensation. Healing occurs in 3 to 8 weeks with scarring present. The facility's 9/2015 Skin Injury Policy showed any resident injury of skin must be addressed as follows: 2. Nurse must assess injury, 4. Injury must be documented in the care plan, 8. Update care plan interventions to prevent further injuries. The facility's 2017 Food Safety: preventing Burns Policy showed hot and food and beverages will be served at a safe temperature to prevent burns. Staff will monitor hot beverages on a regular basis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm at the point they are served. Appropriate supervision to obtain hot beverages will be provided to any individual demonstrating decreased safety awareness and/or anyone who is at risk for burns or scalds. This policy showed water temperatures at 150 degrees take less than a second to cause second degree burns. Hot liquids at 140 degrees may cause second degree burns in 3 seconds. Residents Affected - Few 2. R9's face sheet showed an [AGE] year-old female with diagnosis of dementia with psychotic disturbance, need for assistance with personal care, weakness, and chronic kidney disease. R9's 8/4/22 facility assessment showed R9 had severe cognitive impairment. R9's 12/11/22 facility assessment showed she required extensive assistance of two plus persons to physically assist with bed mobility, dressing, toilet use, and personal hygiene. This assessment showed R9 required limited assistance of one person to physically assist her to eat. R9's 1/29/23 incident report showed the resident spilled her full cup of hot cocoa onto her left breast, left side of her abdomen and left arm resulting in three blisters to the left arm. Blister #1 measured 5 cm X 0.3 cm. The second blister measured 12 cm X 3 cm. The third blister measured 10 cm X 2.5 cm. There was a red mark to the left side of the abdomen measuring 6 cm X 4 cm. The intervention initiated for this incident was to put ice into cocoa before it is given to the resident and to move the resident to the feeder table. R9's 1/29/23 progress note showed no wound assessment. The wounds size, color, location, peri wound and other pertinent data. The facility's January 2023 Incident/accident log showed on 1/29/23, R9 had a burn/blister to the left arm from spilled hot cocoa. R9's incident notes and skin/wound notes in her medical record are blank. There was no wound assessment in R9's nursing progress notes and no scanned wound documents. R9's care plan had no interventions to prevent future burns from hot liquids. R9's safety care plan showed she was unaware of her safety needs and forgets her functional limitations due to progression of dementia. R9's activity of daily living care plan showed a deficit related to impaired mobility/cognition due to a history of a stroke with right sided hemiplegia and hemiparesis. R9's cognition care plan showed impaired cognition impairments are evidenced by decreased memory and orientation. On 2/21/23 at approximately 1:50 PM, R9 was in the dementia unit dining area visiting with family. R9 was in a wheelchair. Her left antecubital area was reddened, and had scarred residual of the burn wound. The area was open to air and closed. On 2/22/23 at 11:25 AM, V16, Community Staff Aide, poured hot water into individual cups on the dementia unit. The temperature of the water was 169 degrees Fahrenheit. Hot cocoa mix and ice cubes were added to each cup ,then mixed and served to the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 At 11:30 AM, V16 said they never check the temperature of the hot liquids before serving them to the residents. Level of Harm - Actual harm Residents Affected - Few On 2/21/23 at 1:50 PM, V15, R9's daughter said R9 was burned from hot chocolate. Why would they even serve hot chocolate that hot. She had blisters. 3. R33's face sheet showed an [AGE] year-old female with diagnosis of cerebral infarction, vascular dementia, bilateral optic atrophy, left eye esotropia (deviated toward the nose), head contusion, and aphasia. R33's 5/12/22 facility assessment showed severe cognitive impairment. This assessment showed R33 resided on the dementia unit. R33's 5/12/22 facility assessment showed she required extensive assistance of one-person physical assist for eating, bed mobility, transfer, dressing, toilet use, and personal hygiene. R33's care plan showed she was unaware of her safety needs, overestimates her functional ability and had poor spatial awareness. R33's medical record showed no skin, wound, or incident notes. The facility's May 2022 incident/accident log showed no mention of R33's 5/20/23 burn incident. The facility's 5/20/22 incident report showed R33 spilled hot cocoa in her lap. The report showed bilateral upper thigh redness. The intervention suggested was to put ice cubes to hot liquids. No measurements or complete wound assessment were on R33's record. R33's 5/31/22 wound assessment flowsheet provided by the facility and not part of her electronic record showed diffuse redness. R33's 5/20/22 progress note showed no wound assessment or other data regarding the burn incident circumstances. R33's safety and skin care plans have no mention of the 5/20/22 burn incident and no interventions to prevent additional burns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to ensure a resident was monitored during medication administration for 1 of 1 resident (R20) reviewed for medication administration in the sample of 23. The findings include: On 2/22/23 at 8:38 AM, R20 was seated alone in her room in a wheelchair. R20 was eating breakfast and her food tray was on the table directly in front of her. A clear plastic medication cup with applesauce and semi-dissolved pills were next to the tray. Several white and pink crushed pills were visible through the medication cup. R20 stated she likes to wait to take her morning pills until she is done eating. R20 said the nurses leave her pills with her all the time. R20 said, They (nurses) just trust me that I will take them. V8 (RN-Registered Nurse) entered the room and removed the breakfast tray as soon as R20 was done eating. V8 exited room and the medication cup remained on R20's table. On 2/22/23 at 9:07 AM, V8 (RN) stated, Yes, she (R20) can take her medications by herself. She is usually pretty good at it. She likes to take them her way and at the time she likes. If I try to give them before she is ready, she won't take them so I just leave them in there with her. On 2/22/23 at 1:36 PM, V3 (Assistant Director of Nurses) stated, Residents need to have a mini-cognitive assessment done before they are allowed to take medicines by themselves. A physician order is also needed. The assessment should be updated at least quarterly, or sooner if needed. It is important to ensure the resident is safe to administer their medications correctly. It is unsafe if they do not take them at the correct time or possibly choke on the pills. V3 reviewed R20's electronic medical record and stated there is not an assessment for R20 to have medications left unattended with her. V3 said there may be an assessment in the paper chart. At 2/22/23 at 1:42 PM, V8 (RN) reviewed R20's paper chart, and stated there was no documentation related to R20 self-administering her own medications. R20's physician order sheet, dated 2/22/23, was reviewed and there was no order stating R20 was able to self-administer medications. R20's care plan showed a focus area related to medications, start dated 10/1/21. Interventions included Nurse to monitor for safe swallowing of medications, provide education to resident, chart refusals-make sure I safely swallow meds by observing me take them. The facility's undated Self Administration of Medication policy states: .self-administration competency testing shall be performed by the Nursing Staff . and If self-administration is seen as a possibility for the resident, the physician should be notified by the Nursing Staff for final approval of the resident's self-administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator and freezer free of ice build up, failed to wash hands between touching dirty and clean dishes, failed to use tongs or clean gloves while serving food to the residents, and failed to cover food and drinks being delivered to a residents room. This applies to all residents in the facility. The findings include: The CMS (Centers for Medicare & Medicaid Services) dated 2/21/2023 shows there are 115 residents in the facility. 1. On 2/21/2023 at 8:45 AM, a build up of ice was observed in the back end of the walk-in freezer and near the fans. Next door to the freezer, the walk-in refrigerator was observed to have ice build up on the right side of the wall and in the back right corner. (The right side of the refrigerator and the freezer share this wall.) V9, Dietary Manager, said this has been a problem for a while, and she scrapes it down twice a week to prevent the ice from falling on top of the food, causing contamination to the food below it. 2. On 2/21/2023 at 9:40 AM, V10, Dietary Aide, was observed loading the dishwasher with dirty dishes using her gloved hands. V10 was then observed removing the clean dishes from the dishwasher and putting the dishes away using the same dirty gloves. V9 said V10 should have washed her hands before putting away the clean dishes to prevent cross contamination. 3. On 2/21/2023 at 11:45 AM in the Birch kitchenette, V12 and V13 were observed serving the food to the residents. V13 was wearing gloves while touching the bread, French fries, hamburger patties, and corn on the cob. V13 was observed pulling food from the steam heater and checking the temperature of the food without washing her hands or applying new gloves. V13, with the same dirty gloves, returned to serving the food by using her soiled gloves. V9 said she expects the staff to use tongs when serving foods that can not be served with a spoon. V9 said she should have changed her gloves to prevent cross contamination. 4. On 2/21/2023 at 11:45 AM, during the meal service on the Birch unit, and again at 1:20 PM on the Oak unit, room trays were observed being prepared in the kitchenette. No plastic wrap or lids were used to cover the desserts or drinks. The trays were then passed to the staff in the dining room to deliver to the rooms. The trays for the Oak unit were observed being taken from the dining room to the rooms of R268, R80 and R18. V9 said she expects her staff to cover all foods with a lid or plastic wrap. The facility face sheet for R18 shows diagnoses to include congestive heart failure and type 2 diabetes. R18's POS (Physician Order Sheet) dated 2/2023 shows an order for a general diet with diet desserts. The facility face sheet for R80 shows diagnoses to include pneumonia and type 2 diabetes. The POS dated 2/2023 for R80 shows a diet order for a general diet. The facility face sheet for R268 shows diagnoses to include post polio syndrome and hypertension. The POS dated 2/2023 for R268 shows a diet order for a general diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete The facility provided as a policy, dated 3/17, the general HACCP (Hazard analysis and critical control points) to use one person to load dirty dishes and another to pull clean dishes from the dishwasher. The facility policy dated 2017 for Bare hands contact with food and use of plastic gloves, 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task, used for no other purpose and discarded when damaged or soiled or when interruptions occur in the operation. No policy was provided by the facility regarding ice build up in the freezers or for covering food when it leaves the kitchen. Event ID: Facility ID: 145547 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure wound care and medication administration were performed in a manner to prevent cross-contamination for 2 of 8 residents (R32, R64) reviewed for infection control in the sample of 23. Residents Affected - Few The findings include: 1. R32's admission Record, printed by the facility on 2/22/23, showed he had diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side (weakness and paralysis of one side of the body following bleeding in the space between the brain and the tissue covering the brain), and cervical spondylosis (a degenerative disease that affects the neck). R32's facility assessment, dated 1/1/23, showed he had moderately impaired cognitive skills for daily decision making. R32's Progress note, dated 2/14/23, showed he spilled coffee on himself and had partial skin loss and blistering on his right foot. R32's Pressure/Skin care plan showed Treatments to right foot as ordered. R32's ADL (activities of daily living)/Self-Care Performance care plan showed he had an ADL self-care performance deficit related to impaired mobility/cognition due to a history of CVA (cerebrovascular accident-stroke) with right-sided hemiplegia and hemiparesis. The care plan showed R32 required extensive assist of staff for bed mobility, dressing and personal hygiene. R32's Wound Evaluation and Management Summary (from a contracted Wound Physician), dated 2/17/23, showed he had a burn wound of the right, dorsal (upper side) foot for at least three days duration. The evaluation summary showed the wound measured 13.5 centimeters (cm) x 4.9 cm x 0.1 cm. On 2/23/22 at 9:43 AM, V4 (Wound Nurse) removed the old dressing to the wound on R32's right foot. R32 had a large open blister that extended from the top section of his right foot, along the side and across a portion of the bottom of his foot. V4 cleaned the wound bed with wound cleanser, wiped the skin around the wound with the gauze and wound cleanser, then wiped back over the wound bed using the same section of the gauze. V4 dried the wound bed with gauze, dried the skin around the wound with the gauze and then wiped over the wound bed with the same section of gauze. V4 applied a xeroform dressing (an occlusive dressing that protects the wound) to the wound and wrapped the wound with rolled gauze. On 2/23/23 at 10:25 AM, V4 said she should not have cleaned the skin around the wound bed and then wiped the open wound so she did not introduce bacteria into the wound. On 2/23/23 at 10:32 AM, V5 (Registered Nurse-RN) said you should not clean the skin around the wound and then wipe the wound bed with the same gauze for infection control, So you do not introduce bacteria into the wound. On 2/22/23 at 1:27 PM, R32's electronic orders tab showed: Cleanse right medial foot and right dorsal foot wounds with wound cleanser. Pat Dry. Apply Xeroform gauze daily. Wrap with Kerlix Roll (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Gauze. Change daily. Started on 2/18/23. Level of Harm - Minimal harm or potential for actual harm The facility's policy and procedure titled Wound Care/Dressing Change, with a review date of 5/2015, showed Procedure .9. Use gauze pads or swabs and ordered cleaning solution to clean incision/wound. Working from top to bottom, and from clean to dirty, wipe once to bottom and then discard pad/swab. Repeat as often as necessary, discarding each pad/swab in biohazard bag. Residents Affected - Few 2. R64's admission Record, printed by the facility on 2/22/23, showed he had diagnoses including type II diabetes mellitus, vitreous hemorrhage right eye (a leakage of blood into the areas in and around the clear gel that fills the space between the lens and the retina of the eye), and glaucoma. R64's Order Summary Report, printed by the facility on 2/22/23, showed orders for Novolog insulin 35 units subcutaneously before meals. The Order Summary Report showed another order for Novolog insulin per sliding scale before meals and at bedtime. The order showed give in addition to the scheduled insulin. The Order Summary Report showed an order for artificial tears solution, instill one drop in both eyes four times a day for dry eyes and an order for artificial tears solution one drop in both eyes every six hours as needed for dry eyes. R64's vision care plan, with a target date of 5/23/23, showed he had impaired vision related to diabetic retinopathy. The care plan showed R64 has had several eye procedures and had received frequent injections to his eyes. The care plan showed, Administer eye medications per MD (Medical Doctor) order. R64's ADL (activities of daily living)/Self-Care Performance care plan showed he had an ADL self-care performance deficit. On 2/21/23 at 11:59 AM, V7 (Registered Nurse/RN-Agency) administered 38 units of insulin into R64's left abdomen. After removing the needle, R64 had blood on his abdomen where the needle was removed. V7 wiped the blood from R64's abdomen. V7 left the same gloves on that she used to administer the insulin, and wiped the blood from R64's abdomen and instilled one drop of refresh tears into R64's left and right eyes. On 2/22/23 at 2:27 PM, V6 (Registered Nurse/RN) said after injecting insulin and wiping blood from abdomen, the nurse should change their gloves when moving to another part of the body so you do not cross-contaminate, Especially since you are moving to the eyes. On 2/22/23 at 2:30 PM, V5 (RN) said you should change gloves and clean your hands after giving insulin and wiping blood from the resident's abdomen. V5 said you do not want to cross-contaminate and cause an eye infection. The facility's undated policy and procedure titled Guidelines for Procedures for Both Standard Precautions and Transmission-Based Precautions showed Gloves are worn for three important reasons: 1. To provide a protective barrier and to prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin .2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes or nonintact skin .The following guidelines regarding gloves are recommended .2. Use examination gloves for procedures involving contact or expected contact with body fluids and wash hands. 3. Change gloves between patient contacts, and when going from a more contaminated area to a less contaminated area on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145547 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dekalb County Rehab & Nursing 2600 North Annie Glidden Road Dekalb, IL 60115 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the same resident. The policy also showed Wearing gloves does not replace the need for handwashing, because gloves may have small, in apparent defects or may be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contacts is an infection control hazard. Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident, and wash hands immediately. The facility's policy and procedure titled Insulin Injection Administration Procedures, with a revision date of 2/21, showed 3. Cleanse hands before and after administration of insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145547 If continuation sheet Page 12 of 12